3. even those patients who lack personality disturbances severe enough to warrant a DSM or ICD personality diagnosis often have clinically significant pathology, such as difficulties with intimacy, management of aggression or self-assertion, rejection-sensitivity, etc (Westen, 1997).

There is little question that inclusion of a PD axis in the DSM and ICD, and its refinement through two decades of research, has been a crucial step in the evolution of more clinically and empirically useful diagnostic manuals. Knowing that a patient has major depression is certainly important, but adding the "qualifier" that the patient also has borderline PD is equally important because it has significant implications for prognosis and treatment.

PDs have historically been in a tangential position among diagnostic syndromes, never having achieved a significant measure of recognition in the literature of either clinical psychiatry or abnormal psychology. Prior to the DSM-III and ICD-8, they were categorized in the official nomenclature with a mélange of other miscellaneous and essentially secondary syndromes. Today, PDs occupy a place of diagnostic prominence, having been accorded a contextual role in the multiaxial schema of the DSM. Personality pathologies comprise one of two required "mental disorder" axes in the DSM. Henceforth, clinicians must not only assess the patient's current symptomatology, indicated on Axis I, but also evaluate those pervasive features which characterize the patient's enduring personality pattern, recorded on Axis II. In effect, the revised American multiaxial format requires that symptom states no longer be assessed as clinical entities isolated from the broader context of the patient's lifelong style of relating, coping, behaving, thinking, and feeling - that is, his or her personality.

Personality and its disorders are regarded as a potential diathesis (Tyrer, 2007). There are clinical theorists who assert that it is the patient’s personality that should be evaluated first; only secondarily should the patient’s clinical state be considered. There are substantive reasons for attending to the PDs first, beyond the pragmatics of adhering to official nosological requirements. Lifelong personality traits appear to serve as a substrate, as well as a context for understanding more florid and distinct forms of psychopathology. Since the early 1960s, most societies have been increasingly committed to the early identification and prevention of mental disorders. This emphasis has led clinicians to attend to both premorbid behavioural signs and the less severe variants of emotional disturbance. Ordinary anxieties, minor personal conflicts, and social inadequacies are now seen by many clinicians as the forerunners of more serious problems. A significant impetus to this movement is the emergence of community health centres whose attentions are directed to the needs of the less seriously disturbed. As a result of these developments, the scope of clinical psychopathology was broadened far beyond its historical province of "Hospital Psychiatry." As a field, it now encompasses the full spectrum of mild to severe mental disorders. With personality as a contextual foundation, diagnosticians have become more proficient in understanding personality dynamics and can more clearly trace the sequences through which both subtle and dramatic clinical symptoms unfold.

PDs have been estimated to affect at least 10% of the population, and constitute a large percentage of the patients seen by psychiatrists. Yet unlike other diagnoses, PDs may or may not be associated with subjective symptoms. While some categories show high comorbidity with symptomatic diagnoses such as anxiety and depression, some PDs produce distress in other people rather than in the patient. But in either case, the overall functioning of patients with PDs is often marginally social, comparable in many cases to levels seen in patients with chronic conditions such as schizophrenia.

Numerous studies suggest that PDs are underappreciated causes of social cost, morbidity, and mortality. PDs are associated with crime, substance abuse, disability, increased need for medical care, suicide attempts, self-injurious behaviour, assaults, delayed recovery from Axis I and medical illness, institutionalization, underachievement, underemployment, family disruption, child abuse and neglect, homelessness, illegitimacy, poverty, STDs, misdiagnosis and mistreatment of medical and psychiatric disorders, malpractice suits, medical and judicial recidivism, disruption of psychiatric treatment settings, and dependency on public support. The amount of social cost and disruption caused by the PDs is disproportionate to the amount of attention it gets in the public consciousness, in government research funding, in medical school education or even in psychiatric residency training And no less important than dealing with the social costs of personality disorders is the potential value inherent in preventive programs designed to enhance personality resilience and adaptive capacities.

Personality is seen today as a complex pattern of deeply embedded psychological characteristics that are largely nonconscious and not easily altered, expressing themselves automatically in almost every facet of functioning. Intrinsic and pervasive, these traits emerge from a complicated matrix of biological dispositions and experiential learnings, and ultimately comprise the individual's distinctive pattern of perceiving, feeling, thinking, coping, and behaving.

Personality is the patterning of characteristics across the entire matrix of the person. Rather than being limited to a single trait, personality regards the total configuration of the person’s characteristics: interpersonal, cognitive, psychodynamic, and biological. Each trait reinforces the others in perpetuating the stability and behavioural consistency of the total personality structure. For the personality disorders, then, causality is literally everywhere. Each domain interacts to influence the others, and together, they maintain the integrity of the whole structure.

Personality disorders are not diseases or disorders in the usual medical disease sense. Rather, PDs are theoretical constructs employed to represent varied styles or patterns in which the personality system functions maladaptively in relation to its environment. When the alternative strategies employed to achieve goals, relate to others, and cope with stress are few in number and rigidly practiced (adaptive inflexibility), when habitual perceptions, needs, and behaviours perpetuate and intensify pre-existing difficulties (vicious circles), and when the person tends to lack resilience under conditions of stress (tenuous stability), we speak of a clinically maladaptive personality pattern, that is, a PD.

Distinctions between normality and pathology are largely social constructions or cultural artefacts. Normality and pathology must be viewed as relative concepts; they represent arbitrary points on a continuum or gradient - no sharp line divides normal from pathological behaviour. Among diverse and ostensibly content- and culture-free criteria used to signify normality are a capacity to function autonomously and competently, a tendency to adjust to one’s social milieu effectively and efficiently, a subjective sense of contentment and satisfaction, and the ability to self-actualize or to fulfil one’s potentials throughout the life span into one’s later years.

PDs were noted either by deficits among the preceding or by the presence of characteristics that actively undermine these capacities. Perhaps these criteria are too westernized or Eurocentric to be universal. In some Asian cultures, for example, where the individual is expected to subordinate individual ambitions to group consensus, the capacity to function autonomously might be praiseworthy, but the desire to do so is not. The traits which compose a number of personality styles are likely in certain historical periods or cultures, such as contemporary Western societies, to promote healthy functioning (e.g., Histrionic, Compulsive, Narcissistic traits). Similarly, in this society, there are personality styles and traits that are highly conducive to pathological functioning (e.g., Avoidant, Dependent, Masochistic). There are other personality patterns (e.g., Schizotypal, Borderline, Paranoid) which have a very small probability of falling at the normal end of the continuum in almost all cultures.

The interest in the description of individual differences is very old. In Theophrastus’ Characters, written in the 3rd century BC, 32 different types of human beings are described, some of them familiar to clinicians nowadays (Theophrastus, 1998). In the fourth century B.C. Hippocrates concluded that all disease stemmed from an excess of or imbalance among four bodily humours: yellow bile, black bile, blood, and phlegm. Hippocrates identified four basic temperaments, the choleric, melancholic, sanguine, and phlegmatic; these corresponded, respectively, to excesses in yellow bile, black bile, blood, and phlegm. Although the doctrine of humours has been abandoned, giving way to scientific studies on topics such as neurohormone chemistry, its terminology and connotations still persist in such contemporary expressions as being sanguine or good humoured.

Along the 19th century the concept of pathological personality was forged. Pinel in 1809 described his manie sans délire, that is to say, mental illness without symptoms of illness, to which he later on also referred as folie raisonnante, that is to say, madness without insanity.

J.A. Koch who proposed, replacing the established label moral insanity, with the term psychopathic inferiority Koch used the term psychopathic, a generic label employed to characterize all personality diagnoses until recent decades, to signify his belief that a physical basis existed for these character impairments. The prime psychiatric nosologist at the turn of the century, Emil Kraepelin, did not systematize his thinking on PDs, but in his efforts to trace the early course of these syndromes, Kraepelin "uncovered" two premorbid types: the "cyclothymic disposition," exhibited in four variants, each inclined to maniacal-depressive insanity; and the "autistic temperament," notably disposed to dementia praecox.

The best-known European classification of disordered personalities was proposed by Kurt Schneider. Schneider differed from many of his contemporaries, most notably the prime modern constitutionalist The best-known and perhaps most fully conceptualized of PDs are those formulated by psychoanalytic theorists. Their work was crucial to the development of an understanding of the causal agents and progressions that typify the background of these disorders. It was Sigmund Freud and his younger associates, Karl Abraham and Wilhelm Reich, who laid the foundation of the psychoanalytic character typology h.

Although numerous analytic theorists have continued to contribute to the study of character, the contemporary work of Otto Kernberg deserves special note. Taking steps to develop a new psychoanalytic characterology, Kernberg constructed a framework for organizing personality types in terms of their level of severity to speak of "higher, intermediate and lower levels" of character pathology; both intermediate and lower levels are referred to as "borderline" personality organizations.

Note should be made of another productive personologist who utilized a mathematical/factorial approach to construct personality dimensions, namely Raymond Cattell (Cattell, RB (1965)). His research has led him to identify 16 primary traits, which he then arranged in sets of bipolar dimensions that would undergird personality types. Other contemporary quantitative contributors include Peter Tyrer (Tyrer, 1988) and W. John Livesley (Livesley, 1987).

In a model which seeks to draw on genetic and neurobiologic substrates, Robert Cloninger has proposed a complex theory based on the interrelationship of several trait dispositions. Another biosocial model using three pairs of evolutionary polarities as a basis is one developed by Theodore Millon. Here, he derived a PD taxonomy that subsumed the dependent, independent, ambivalent, and detached coping styles with an activity-passivity dimension. Notably, in their recent work, numerous theorists have begun to turn their attention to positive mental health, speaking of personality resilience and adaptive capacities.

Two classificatory systems of mental disorders are recognized internationally today, namely, the Diagnostic and Statistical Manual of Mental Disorders - 4th Edition-Text Revised (DSM-IV-TR)19 and the International Classification of Mental and Behavioural Disorders (ICD-10)20. Personality disorders are given important weight in both classifications. The DSM-IV-TR places them in its separate Axis II (this classification comprises five such axes). The personality disorders in the DSM are grouped into three clusters, based essentially on empirical descriptive similarities; this cluster grouping has not (and maybe never will be) been satisfactorily validated but its widespread use indicates a frequent wish to reduce the number of categories. Cluster A includes paranoid, schizoid and schizotypal personality disorders (the so-called odd or eccentric individuals), Cluster B comprises antisocial, borderline, histrionic and narcissistic PDs (the ostensible dramatic, emotional or erratic individuals), and Cluster C includes avoidant, dependent and obsessive-compulsive PDs (anxious/fearful individuals). A last category, "PD not otherwise specified," comprises disorders of personality that do not fulfil the specific criteria for any of the above individual PDs.

The ICD-10 Classification includes a single section covering all personality abnormalities and persistent behavioural disturbances. This is separated into specific named personality disorders, mixed and other personality disorders, and enduring personality changes. The individual personality disorders are paranoid, schizoid, dissocial, emotionally unstable (impulsive and borderline types), histrionic, anxious (avoidant), anankastic and dependent ones. Two more categories are "other specific PDs" and "PD, unspecified." The ICD classification is similar to that of DSM-IV, although differences are noteworthy. For example, the borderline PD of the DSM-IV is subsumed as one of the two emotionally unstable disorders in ICD-10, the obsessive-compulsive adjective in DSM-IV is retained as "anankastic" in ICD-10, and avoidant personality disorder is only a partial equivalent of the ICD-10 anxious personality disorder. Two more disorders included in the official section of the DSM-IV are excluded from ICD-10; schizotypal disorder is a variant within the schizophrenia spectrum of conditions in ICD-10 and narcissistic personality disorder is only mentioned in the section on "other specific PDs" in ICD-10, without any specific criteria noted for this diagnosis. The ICD-10 contains other general categories that refer to PDs that have no counterpart in the DSM-IV, such as "mixed disorders" and "other disorders of adult personality and behaviour."

Five broad sources of information are available to help describe the clinical problem; each has its own advantages and limitations.

The first comprise clinical interviews and observations; the clinician observes and asks the questions and the subject responds verbally, often in a free-form style. The clinician is free to follow any particular line of questioning desired and usually mixes standard questions with those specific to the current problem.

The second is structured or semi-structured interviews. Open ended, free form style clinical interviews may provide insufficient information to assess the different personality disorders. Interviewer- administered interviews, structured or semi-structured, systematically address and assess each personality disorder criteria with standard questions or probes. The most often used are International Personality Disorders Examination (IPDE), Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) and

The third second are formal rating scales and checklists; a person familiar with the subject completes those forms in order to provide an objective perspective. Rating scales and checklists often serve as a memory aid, ensuring that everything relevant to the disorder is included in developing a treatment plan. Rating scales usually have more items than the diagnostic criteria for the same syndrome and are usually held to a higher standard of scientific rigor. Because they have more items, they provide more fine-grained measurements, but they also take more time to complete. For example, the revised Psychopathy Checklist (PCL-R) consists of 20 items, whereas the DSM-IV offers only seven criteria for the diagnosis of antisocial PD. Although the PCL-R is widely used in the study of psychopathy, few rating scales exist for use with other PDs.

The third source is the self-report inventory; subjects literally report on themselves by completing a standard list of items. Because self-reports represent the subject’s own responses, they can be especially valuable in quickly identifying clinical symptoms. Unless the individual is violent or psychotic, a self-report inventory can be given at any point during the clinical process, often with minimal supervision. A profile obtained at the beginning of therapy, for example, can be used as a baseline to evaluate future progress. A number of other self-report instruments are available. The Tridimensional Personality Questionnaire (TPQ),, Millon Clinical Multiaxial Inventory (MCMI-III), Neuroticism-Extroversion-Openness- Personality Inventory Revised (NEO-PI-R), The Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP), The Schedule of Nonadaptive and Adaptive Personality (SNAP) are the most often used self-report assessment instruments.

The fourth source of information is projective techniques, an attempt to access unconscious structures and processes that would not ordinarily be available to the subject at the level of verbal report. These techniques seek to draw out internal, and frequently unconscious, influences on behaviour by presenting the subject with inherently unstructured, vague, or ambiguous situations. The Rorschach Inkblot Test is the classic example. The subject is presented with a series of 10 blots in turn and asked to report what he or she sees. The Thematic Apperception Test uses pictures of various interpersonal situations. The subject constructs a story to explain what is happening in the picture, what led up to these events, and how matters will end. Because projective instruments are time-consuming and not widely regarded as being as psychometrically sound as self-report inventories, their use has waned in recent years, especially with the economic constraints of managed care.

Finally the use of inmates (informants) of the subject, perhaps a spouse, teacher, parent, or good friend, someone who can provide perspective on the problem, might also be considered another important source of information.

The official classification systems reflect a variety of personality related issues that are likely to be solved in the near future with the revision of both systems.

First, there is the question of the retention of personality disorders on a different axis (Axis II) from that of clinical syndromes (Axis I) in the DSM-IV. The division between Axis I and Axis II seems to some to be arbitrary and not justified adequately.

A second persistent problem is the classificatory status of the individual categories of personality disorder. There is great overlap between the criteria for diagnosing personality disorders in both DSM-IV and ICD-10 and this seriously compromises their validity as separate disorders. Clear differentiation between the disorders is often difficult and many individuals diagnosed with a personality disorder have several other personality disorders that do not always appear to be fundamentally different.

A third issue is the overlap of some personality disorders with disorders in Axis I. An example is the relationship between avoidant PD and generalized social phobia, both of which address the same group of symptoms without a clear distinction between them. Although still included in the Appendix B of DSM-IV, there seems to be a similar problem between depressive personality disorder (Axis II) and dysthymia (Axis I).

A fourth question is how many personality disorders deserve separate description in the two classification systems? It is also uncertain what type of criteria should constitute the building blocks of personality disorder and how many of them are needed for each diagnosis. Both classifications rest mainly on historical traditions and committee consensus rather than on empirical data or well-constructed theoretical grounds. Many of the assumptions of each classification are implicit or covert and need to be exposed so that diagnosis can be made consistently and subjected to systematic testing. Fifth, there are also many questions about the division between "normal" personality and personality disorders that need answering and whether it is wise to have a division at all.

Sixth, another major controversy in the field is the categorical/dimensional/prototypical controversy, to which we will turn shortly. A further issue is the polythetic criterion lists used in current classification systems; these produce considerable intragroup variability such that two people with the same diagnosed PD may display very different features because they score for different sections.

Finally seventh , as already mentioned, PDs are tied to cultural variables to a much greater extent than the clinical disorders in Axis I, creating difficulties when diagnosing this kind of disorders across different cultures, a topic we will also address in a later section.

Given the need for a clear unambiguous official classificatory system for personality disorders and the dissatisfaction with the current two systems, there are likely to be important changes in the classification of personality disorders in DSM-V and ICD-11. Perhaps the most important question is "how do we improve the clinical utility of the classification of personality disorders so that it is recognised to be helpful in decision-making at all levels?"

A general definition of personality disorders are provided in DSM-IV-R and in ICD-10. It can be useful to psychiatrists and clinical psychologists, because the most common diagnosis in clinical practice is the diagnosis "not other specified" (Clark et al. 1995)

General criteria diagnostic criteria for a Personality Disorder (ICD-10)

A specific personality disorder is a severe disturbance in the characterological constitution and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption. Personality disorder tends to appear in late childhood or adolescence and continues to be manifest into adulthood. It is therefore unlikely that the diagnosis of personality disorder will be appropriate before the age of 16 or 17 years. General diagnostic guidelines applying to all personality disorders are presented below; supplementary descriptions are provided with each of the subtypes.

Diagnostic guidelines

Conditions not directly attributable to gross brain damage or disease, or to another psychiatric disorder, meeting the following criteria:

(a) markedly dysharmonious attitudes and behaviour, involving usually several areas of functioning, e.g., affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;

(b) the abnormal behaviour pattern is enduring, of long standing and not limited to episodes of mental illness;

(c) the abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;

(d) the above manifestations always appear during childhood or adolescence and continue into adulthood;

(e) the disorder leads to considerable personal distress but this may only become apparent late in its course;

(f) the disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations. For diagnosing most of the subtypes listed below, clear evidence is usually required of the presence of at least three of the traits or behaviours given in the clinical description.

Jacob is a 26 years old man. Despite extraordinary intelligence John was not able to complete or participate in any educational program. He wanted to have a normal life with a family and friends, but thought that he was rootless and he felt that other people thought that he was peculiar or odd. He felt that he was outside. As a child he went to various schools because his parents moved around. He was thought of as a lonely wolf and did not participate in the social life or games of sports with his peers. During school class he was often absent minded being absorbed in his own thoughts and fantasies. From around the age of thirteen he became interested in computers and was quite advanced in his understanding of mathematics. He became exceedingly isolated with his computer as his sole companion.

This vignette schizoid personality illustrates the difficulties how to establish a stable relationship to significant others like peers and family. Often it is regarded as unusual that a person with schizoid personality disorders complains by himself or herself to be isolated. Many schizoid patients, in the contrary, claim to be quite satisfied with their loneliness and it is quite unusual that he wish to have a family. Also schizoid persons usually accept their situation or even deny any desire for closer relationships.

The central feature of Schizoid Personality Disorder (SPD) is a pattern of pervasive social detachment and a narrow range of emotional expression in social settings. The DSM-IV criteria for SPD differ in detail in three criteria from the ICD-10 diagnostic criteria. The both describe the SPD by seven criteria, of which at least three must be applicable. The SPD is most clearly defined within relationships. Individuals with this disorder are characterized by a profound defect in their ability to form personal relationships or to respond to others in an emotionally meaningful way and appear to lack a desire for intimacy. They are introverted, aloof, and seclusive, and select activities that do not include much interaction with others. This style of life easily results in social isolation.

Differential Diagnosis

The differential diagnosis of SPD includes:

1. a normal preference for solitary pursuits that does not meet the criteria for schizoid personality disorder;

3. schizotypal personality disorder (in which there are cognitive and perceptual distortions); In contrast to the schizotypal personality disorder the SPD does not include psychotic-like cognitive/perceptual distortions.

5. avoidant personality disorder (in which the patient has a fear of being embarrassed or inadequate, with excessive anticipation of rejection);

6. obsessive-compulsive personality disorder (in which there may be apparent social detachment that arises from devotion to work and discomfort with emotions; capacity for intimacy is usually preserved);

The most frequent co-occurring personality disorders with SPD are schizotypal and avoidant personality disorders and to a lesser degree paranoid, antisocial and borderline personality disorders (Kalus et al. in Livesley, 1995, p.65). The highest co-occurrences may perhaps be because of the high overlap between the two criteria sets. The SPD and the schizotypal personality disorder, for example, share the important criteria of social isolation and restricted affect. Also the avoidant personality disorder may seek isolation, but individuals with SPD will tolerate the separation with comfort, while individuals with avoidant personality disorder will be distressed and lonely. SPD can an antecedent disorder to schizophrenia, major depression, dysthymia or a delusional disorder. Further it shows high comorbidity with social phobia and agoraphobia. If people with SPD are detached from a supportive family they often become involved with drugs and alcohol.

Prevalence

SPD is uncommon in clinical treatment settings. SPD is diagnosed more frequently in males who seem to be more impaired than females with SPD.

Etiology

The etiology of SPD has not been established. A close genetic relationship to schizophrenia has been proposed but is doubtful. Conversely, introversion has been shown to be a highly heritable personality trait. Psychological theories suggest sociocultural factors in the genesis of the disorder: In the psychodynamic approach, the SPD emerges from inadequacies in earliest relationships with parental figures. The cognitive approach suggests that the most important source of dysfunctional behaviour and affects lie in incorrect attributions that people make.

Treatment

As patients with SPD have few complaints and do not seek an interpersonal context for solving their problems, they rarely seek therapy. The disorder is most likely to come to medical attention in the course of intervention for another condition, in response to acute stressors or because of family influence. Others who come into treatment are forced to do so by family or even the legal system. Acutely stressful situations often require crisis intervention. Aims of long-term psychotherapeutic interventions are to maintain stability and support, to improve social skills and comfort, to help maximize quality of an isolated lifestyle. In treatment, clients with SPD challenge service providers with the absence of response. As they do not response to emotional leverage, therapists easily feel frustrated and ineffective. The contact between therapist and patient should be an important element of the therapy. An important step of the therapy should be to open possibilities to make new experiences and changes (Saß and Jünemann, 2001). The therapist should be aware that major changes and modifications of character structure are unlikely. The therapy should be aimed at achieving modest reductions in social isolation and in prompting more effective adjustment to new circumstances (Kalus et al. in Livesley, 1995). Behavioural psychotherapy can be helpful for some patients including, for example, methods such as problem solving, social skills training or role plays. Educational strategies may be effective in working with individuals with SPD to identify (1) their own emotions; (2) the emotions they elicit in others; and (3) possible feeling states of people with whom they relate. Intervention with individuals with SPD may include methods of cognitive therapy, e.g., exploring their self-concept and sense of where they belong in the world. Confrontation should clarify the relation of emotions to thinking and encourage these clients to be present with reality. Individual psychoanalytically oriented psychotherapies are less likely to succeed (Kalus et al. in Livesley, 1995, p.66). Most psychopharmacological interventions apply to comorbid disorders such as depression or anxiousness.

A 37 year old, unemployed man claimed of recurrent irrational thoughts, compulsive behaviour, and social isolation. Since his childhood he had always been eccentric, withdrawn with no real friends anxiously fearing closer relationships, preoccupied with reading stories about Dracula and other myths. He didn’t share his inner thoughts or feeling with anybody, including his parents. He never finished an education, but worked in factories, often at night. Some years earlier he started doubting if his work was accurate enough. Although he recognized these thoughts as irrational, he started spending a lot of time controlling his work over and over again. Soon these compulsive controls took so much time that he could not finish his work, was continuously annoyed by intrusive vivid homosexual images, was preoccupied with doubts concerning almost everything at home and also he had to look persistently at people in order to be sure to maintain their images in his memory. He started fearing that people could notice his behaviour, and he felt that unknown people were staring at him and that they secretly were making fun of him. He complained of being unable to reveal his feelings and thoughts to other people and felt isolated. He started drinking alcohol to control his increasing anxiety. He adopted different peculiar strategies, which ended in new vicious circles of obsessive symptoms and suspiciousness.

This case is diagnosed with obsessive-compulsive disorder (OCD), Alcohol abuse and Schizotypal Personality Disorder. He had long lasting personality difficulties like suspiciousness, odd behaviour and social anxiety prior to the OCD symptoms. Comorbidity is often seen in Schizotypal Disorder, and it is the axis I disorders that usually brings the patients to treatment.

Clinical description

The historical roots of schizotypal personality disorder (STPD) are the non-psychotic personality syndromes within the spectrum of schizophrenia.

The definition of schizotypal personality disorder has remained more or less the same during the revisions of DSM and consists in DSM-IV of the following criteria:

(1) ideas of reference (excluding delusions of reference), (2) odd beliefs and magical thinking that influences behaviour and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense;" in children and adolescents, bizarre fantasies or preoccupations), (3) unusual perceptual experience, including bodily illusions, (4) odd thinking and speech (e.g., vague, circumstantial, metaphorical, over elaborate, or stereotyped), (5) suspiciousness or paranoid ideation, (6) inappropriate or constricted affects, (7) behaviour or appearance that is odd, eccentric, or peculiar, (8) lack of close friends or confidants other than first-degree relatives, (9) excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgment about self.

ICD-10 included schizotypal disorder among the psychoses and defined it partly similarly, partly differently from DSM. The only difference between DSM-IV and ICD-10 is that DSM-IV includes "ideas of reference" and "excessive social anxiety," while ICD-10 includes obsessive rumination and micropsychoses. However, ideas of reference are close to suspiciousness, and micropsychoses are close to unusual perceptual experiences, so the only real difference is social anxiety and obsessive ruminations.

Differential diagnosis

As evolving from the spectrum of schizophrenia, the boundaries between schizotypal personality disorder and schizophrenia are not easy to define. The prodromal symptoms of schizophrenia are similar to the schizotypal personality disorder. Thus, retrospectively, "premorbid" may be added to STPD, according to DSM-IV. When fully developed hallucinations and delusions are presented during a one -month period, the diagnosis is schizophrenia. However, a person with delusions or hallucinations plus negative symptoms may show a clinical picture similar to STPD; even so schizophrenia is the correct diagnosis, if the duration requirements are fulfilled. Even more difficult is the differentiation between simple schizophrenia and STPD in ICD-10. In practice, the differentiation is impossible, as the criteria for simple schizophrenia, personality changes, negative symptoms: and reduced social function is indistinguishable from the early developmental phase of STPD. However, simple schizophrenia requires change, while STPD implies no clear starting point.

The possible early start of STPD, however, may make it difficult to distinguish STPD from milder forms of pervasive developmental disorders (autism). As to other psychotic disorders, the manifestation of full-blown delusions (not only ideas of reference and suspiciousness) and hallucinations (not only illusions) preclude any diagnosis of STPD.

The boundaries between STPD and borderline personality disorder are of course difficult to draw, as both personality disorders emerged from the same borderline psychoses concept. They share the pseudo-psychotic and paranoid features, and quite a few people may live an unstable and turbulent life similar to those with borderline personality disorder. Even so, the impulsivity and affective intensity and variability in the borderline personality disorder are not part of the STPD criteria set. Furthermore, those with borderline personality disorder are not expected to display the socially inept and chronically withdrawn pattern of STPD. Instead, some people with borderline personality disorder may withdraw when they get older, as a consequence of using up the patience of their acquaintances and having experienced a brimful of disappointments in their partnerships and relationships.

STPD is close to schizoid personality disorders. The two disorders share the social isolation and the constricted affects. However, STPD has the oddness and the pseudo-psychotic features in addition. In the same vein, those with paranoid personality disorder share the paranoid features with STPD, but not the withdrawal, oddness and pseudo-psychotic features. STPD shares the social anxiety and the tendency to withdrawal with avoidant personality disorder, but not the eccentricity, paranoid features and illusions.

Comorbidity

Avoidant, paranoid and borderline personality disorders were especially highly correlated to STPD. STPD is associated with psychotic disorders including schizophrenia . Furthermore, there seems to be an association with obsessive compulsive and phobic disorders. There may also be an association with dysthymic disorder, panic disorder, somatoform disorders and eating disorders.

Prevalence

Relatively few studies of the prevalence in the general population have been performed. The samples are seldom quite representative, and differently structured interviews are applied, based on different editions of DSM. The most representative studies show a prevalence of 0.7 (Maier et al. 1992) and 0.6 (Torgersen et al. 2001). Those with a higher number of schizotypal traits have less education and more often live alone in the city centre compared with those with a lower number. STPD seems thus more prevalent among men in clinical samples.

Diagnostic assessment

A meta-analysis of the so-called "Big-Five" and personality disorders showed that what characterized those with STPD were first and foremost Neuroticism, second Introversion and third Non-Agreeableness. The pattern was similar to paranoid and borderline personality disorders in Neuroticism and Non-agreeableness, and similar to avoidant personality disorder in Neuroticism and Introversion. Furthermore, STPD was similar to schizoid personality disorder in Introversion, to antisocial and narcissistic personality disorders in Non-agreeableness, and to dependent personality disorder in Neuroticism. There were no similarities to histrionic and obsessive-compulsive personality disorders. Together with borderline personality disorder, those with STPD were extreme on most personality disorders, three out of five dimensions.

The results of the studies of the relationships between STPD and personality dimensions fit in with the large overlap between STPD and paranoid, avoidant and borderline personality disorders. A study of the relationships between personality disorders and Cloninger’s temperament and character scales suggests that STPD is negatively correlated to Self-directedness and Cooperation, and positively correlated to Self-transcendence. The results illustrate the vulnerable, withdrawn and psychotic-like aspects of STPD. Even if STPD is correlated to common personality dimensions one cannot jump to the conclusion that STPD is a construct based on these dimensions. It may be that those with schizotypal traits simply answer in an extreme way when these dimensions are measured by the questionnaires.

Then we approach the question about the categorical or dimensional nature of schizotypal features. Some statistical analyses suggest that that a latent discontinuity underlies the variation in schizotypal traits (Lenzenweger & Korfine, 1995). Others believe more in a dimensional model of schizotypy, with poorly functional individuals at one end of the dimensions, and well-functioning individuals among those with somewhat lower scores on schizotypal inventories (Goulding, 2004). Those more poorly functioning are more anhedonic and with more cognitive disturbance, while those well-functioning are more characterized by unreal experiences.

Etiology

STPD is genetically influenced as are other personality disorders (Torgersen 1986; Torgersen et al. 2000; Kendler & Hewitt, 1992). This is also the case for schizotypal traits in children (Coolidge et al. 2001). However, what is especially important is the genetic relationship to other mental disorders. Some studies suggest a familial relationship between STPD and the whole realm of psychoses (Squires-Wheeler et al. 1989; Kendler et al. 1995). As STPD evolved out of the familial schizophrenic spectrum, the genetic relationship to schizophrenia is of particular interest. Studies of co-twins of schizophrenic patients (Torgersen, 1992), and biological relatives of adopted-away schizophrenics (Kendler & Gruenberg, 1984) confirmed the specific familial and genetic relationship between STPD and schizophrenia. No other personality disorders seem to be consistently related to schizophrenia.

However, STPD as defined by DSM does not seem to cover adequately the schizophrenia-related STPD. Those adopted-away offspring of schizophrenics who develop personality disorders seem to experience frequent somatoform complaints and poor social function in addition to withdrawal and emotional constriction (Gunderson et al. 1983). In fact, STPD consists of two syndromes that may be independently inherited (Siever, 1995; Kendler and Hewitt, 1992), a constricted/eccentric syndrome that is characterized by odd and eccentric appearance and behaviour, thoughts and communication, and a psychotic-like syndrome that is characterized by ideas of reference, magical thinking, illusions and depersonalization/derealization. While the former syndrome seems to be genetically related to schizophrenia (Torgersen, 1993), the latter is not. Even if there might exist a familial relationship between STPD and affective disorder, a genetic relationship to major depression is not confirmed.

We do not know what environmental factors influence the development of STPD. A retrospective study showed that those with STPD more often reported neglectful parenting from both parents, which means little love and also little control (Torgersen & Alnæs, 1992). Those with borderline personality disorder more often reported affectionless control, meaning little love and much control. Those with other personality disorders more often experienced affectionate constraint; much love and much control, while those without personality disorder reported optimal parenting; much love and little control.

Course and prognosis

A Norwegian twin study showed that those with STPD had poor social as well as occupational adjustment (Torgersen, 1986). Skodol et al. (2002) found dysfunction in relation to parents, sibs, and friends, occupational dysfunction, and dysfunction in relation to more distant family members among those with schizotypal personality disorder. Quality of life is also reduced among those with STPD (Cramer et al. 2003). They have a poor subjective well-being, poor self-realization, less contact with friends and family, less social support, a lot of negative life events, poor neighbourhood quality, and generally a poorer global quality than those without STPD in the general population. Among the personality disorders, nobody displayed poorer quality of life than those with STPD.

The neuropsychological and biological fundamentals of STPD are far from settled. Even so, some results are forthcoming. There seems to be a difference between the constricted/ eccentric and the psychotic-like STPD syndromes. Neuro-psychological tests measuring attention and information processing observe impairment among those with constricted/eccentric traits (Siever, 1995). Indication of a low dopamine level are found among those with the constricted/eccentric syndrome, for instance by a low concentration of homovannilic acid (HVA). An adequate dopamine activity is necessary for maintenance of working memory, a function necessary for social engagement as well as other executive functions.

The deficient information processing may contribute to the social withdrawal, emotional constriction and eccentricity among those with STPD. On the other hand, those with the psychotic-like syndrome seem to have an exceptionally high level of dopamine-activity, as also demonstrated in a high concentration of HVA. The increased dopaminergic activity may explain the psychotic-like traits such as illusions, paranoid ideations etc.

Treatment

Usually psychotherapeutic approaches are applied for patients with STPD. No controlled results are published. However, from clinical experience there are some precautions that are important to take into account. Some less experienced clinicians may be fascinated with all the grotesque and symbol-rich material patients with STPD may produce. They show interest, ask for details and encourage the patient to tell more. This can be great for the clinician, but hardly helpful for the patient. The patient may slide even more into the disturbing inner fantasies. A better approach is to dedramatize the strange thoughts and pictures, not reject, if the patient is active in telling, not refrain from showing a strong interest in the material. Instead, it is important for the patient to learn social skills, to discuss what went wrong in interpersonal situations, what behaviour is common and appropriate.

As to pharmacotherapy, the best approach is to treat the axis-I disorder in cases where those with STPD have it in addition. If the clinical picture is dominated by psychotic-like features, neuroleptic may be the treatment of choice. There are some indications that blocking of dopaminergic activation may help those with psychotic-like traits. On the other hand, those with constricted/eccentric features may be helped by drugs that functions like amphetamine - releasing dopamine and blocking its reuptake.

A 36 year old divorced worker developed a severe depression after he was fired from his job and subsequently had severe alcohol problems. He presented himself to the general practitioner with somatic complaints, anxiety, compulsively washing his hands, fatigue, disturbing inner feelings of hatred towards other people. His troubles started in his childhood. He reported that he was very aggressive towards other children and he was involved in recurrent conflicts. At home he was constantly on guard. In his work relations he was involved in severe interpersonal conflicts, reacting with aggressive attacks at the slightest offences. The last years he spent working, he was continuously involved in conflicts with his colleagues. After a short contact with a female colleague who terminated the relationship with him. The only person he stayed friends with was his brother-in-law who lived a hundred kilometres away. This vignette illustrates important issues and characteristic features of the paranoid personality. First, they do not seek treatment unless they are in a crisis (fired from job) or because of additional pathology (depression). Second, when decompensated they most often get depression, panic attacks, OCD, somatoform disorder as in this case or in other cases an additional alcohol abuse. Third, the vignette may support a psychodynamic formulation of key elements in his personality functioning. His personality pathology is excessive aggression and mistrust.

Paranoid personality disorder is a clinically well-recognized disorder that has not, however, been the object of a great deal of investigation. Although noted in the writings of psychiatrists since the late 1800's, the condition was first called "paranoid personality" by Kraepelin in 1921 (Akhtar, 1990).

The hallmark criteria regarding paranoid personality disorder (PPD) are distrust and suspiciousness of others such that others are seen as purposefully attempting to harm one in some way without any evidence to suggest this is the case. Those with paranoid personality disorder also may be very critical of others, argumentative and rigid in beliefs, again stemming from harbouring unwarranted suspicions about people around them. This often leads to problems with relationships, both personal and in the work place.

The ICD-10 lists seven criteria (see above) of which only three must be met. The current criteria for diagnosing paranoid personality disorder in DSM IV-TR includes seven symptoms of which at least four must be met. Most are essentially the same as the ICD criteria. These include suspicion that others are harming or deceiving one in some way, preoccupation with doubts about the loyalty of friends, reluctance to confide in others out of fear that information may be used against them, reading threatening meaning into benign events, bearing grudges over insults or slights, hasty and angry reaction to perceived attacks on character, and unjustified suspicion regarding the fidelity of a spouse or partner.

There is one criterion that does not exist in the DSM IV and that is "tendency to experience excessive self-importance, manifest in a persistent self-referential attitude." This item, basically implying a level of grandiosity, also did not exist in the DSM III or III-R versions.

Differential diagnosis

Paranoid personality disorder must be diagnosed to the exclusion of schizophrenia, or any other psychotic disorder including psychosis in the context of a mood disorder. Paranoid personality disorder is considered "premorbid" if it is present prior to an Axis I psychotic disorder.

Comorbidity

There is substantial comorbidity of Axis I disorders; individuals with paranoid personality disorder appear to have an increased likelihood of developing depression, agoraphobia, obsessive compulsive disorder and alcohol or substance abuse or dependence. With regard to comorbid personality disorders, there is some variation in the literature. Generally though, it has been suggested that in clinically based samples, over 75% of patients who met paranoid personality disorder criteria also met criteria for other personality disorders, the most common were found to be schizotypal and narcissistic.

One area of research is the possible relationship of PTSD with paranoid personality disorder. When 180 outpatients were analyzed using the DSM III-R, subjects with paranoid personality disorder had a higher rate of comorbid PTSD than subjects without the disorder (29% compared with 12%) (Golier et al. 2003). In addition, they had elevated rates of physical abuse and assault in childhood and adulthood (54% compared with 35%). This suggests a possible link between trauma during early events in life and subsequent paranoid behaviour and mistrust.

Another area that has received some attention is the relationship of violence to paranoid personality disorder. Paranoid cognitive personality style was found to increase the risk of violence in subjects with personality disorders, particularly schizophrenia spectrum disorders (Nestor, 2002).

Prevalence

According to the DSM-IV, the prevalence of paranoid personality disorder was 0.5 to 2.5% in the general public, and more common in males. Interestingly, the 1997 National Survey of Mental Health and Wellbeing (conducted in Australia) using the ICD-10 to assess personality disorders found a 1.34 % prevalence of paranoid personality disorder and no sex difference, despite the similarities in criteria between the DSM and the ICD.

There is some current evidence that paranoid personality disorder may be more difficult to diagnose than other personality disorders. A study of interrater reliability using DSM IV achieved good agreement. However, in the same study, when analyzing test-retest reliability based on how consistent a patient’s report is from one clinician to another, and how information is interpreted and scored, paranoid personality disorder had the lowest reliability of all the personality disorders (Zanarini et al. 2000).

Etiology

It has been suggested that paranoid personality disorder may be related to certain Axis I disorders, including schizophrenia and delusional disorder. Kendler found a much higher risk of paranoid personality disorder in first degree relatives of those with delusional disorder as opposed to relatives of those with schizophrenia, 4.8% compared to 0.8% (Kendler et al. 1985).

On the other hand, paranoid personality disorder was significantly more common in the biologic relatives of patients with schizophrenia when compared with relatives of controls (Kendler et al. 1982).

Using data from the Roscommon family study, an epidemiologic study conducted in Ireland, it was discovered that biological relatives of those with schizophrenia had a significantly higher amount of paranoid personality disorder compared with relatives of controls (Kendler et al. 1993).

As with other disorders, cultural factors must be taken into account in diagnosing this disorder. There are some groups that might, for reasons of maltreatment, language barriers, and unfamiliarity to this society, display what could be labelled paranoid traits. Those groups include: minority groups, immigrants and refugees. In an epidemiologic study recently completed on personality disorders, minorities such as blacks, Hispanics and Native Americans were at greater risk for having paranoid personality disorder than whites (Grant et al. 2004). Also according to the same study, paranoid personality disorder was more common among younger people (18-29), those with lower incomes, and those who were divorced or never married. Some of these findings are not surprising, taking into account the nature of paranoid personality disorder. However, this does bring up the question of which came first: Are some paranoid traits the result of maltreatment by others due to socioeconomic status, race, etc., or does the disorder contribute to, for example, inability to succeed professionally or remain in a relationship? There appears to be a combination of both, which can contribute to complications in diagnosing the disorder.

Course and Prognosis

Paranoid personality disorder can be noted first in childhood; symptoms observed include solitariness, social anxiety and odd thoughts and language. There is not a lot of data regarding the course and prognosis of the disorder. This is likely due to the fact that as it is a personality disorder, it tends to be stable over adult life and although it can cause interpersonal problems, does not often require treatment. It has been observed that the course of the disorder rarely worsens or goes into remission (Akhtar, 1990).

Treatment

There is no specific treatment or medication for paranoid personality disorder. When existing in conjunction with other personality disorders, i.e., borderline personality disorder, treatment may be sought but that is primarily due to symptoms experienced in other personality disorders. There is some data on the effectiveness of day treatments for patients with personality disorders in general (Karterud et al. 2003). Treatment results, although effective for some personality disorders (i.e., borderline), were the poorest for those with paranoid, schizoid, and schizotypal personality disorders.

This is a 27 year old male who committed murder at age 17. He stayed in a high-security hospital for 10 years and started individual treatment after being released. He was an intelligent boy who did well in school until his peers began to tease him. This made him feel helpless and unable to defend himself. At home, however, he felt strong and supportive of his mother. His father lived with another woman. He experienced him self as a looser among his pears but as a winner with his mother. At the end of primary school his father, who then had accumulated substantial wealth, returned home, and the parents resumed their marriage and intimacy. His situation at school changed as he became popular and the teasing stopped, but he still felt insecure and uneasy. He decided to attend karate school to gain a sense of power. A peer introduced him to the criminal milieu where he felt accepted and appreciated. During a robbery he became incredible angry and physically violent without really understanding why. The victim died as a consequence of his attack. He was send to prison for 2 years, followed by a high security hospital for treatment. While he accepted his prison sentence he protested treatment in psychiatric hospital. He was suspicious, remained non-relative and was often restrained due to anger outbursts. A therapist confronted him with the fact that his behaviour could lead to prolonged hospital stay and pointed to his choice of future inside or outside the hospital. This was turning point that made him focus on goals and training for a future out in real life. After discharge he continued to work on self-esteem and trustworthiness, shame and guilt and how to understand, control and come to terms with his anger. Two years later he was married with a son, and pursued a career as a teacher.

Clinical description

Diagnostic Criteria ICD-10

F60.2 Dissocial personality disorder

Personality disorder, usually coming to attention because of a gross disparity between behaviour and the prevailing social norms, and characterized by:

(a) callous unconcern for the feelings of others;

(b) gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations;

(c) incapacity to maintain enduring relationships, though having no difficulty in establishing them;

(d) very low tolerance to frustration and a low threshold for discharge of aggression, including violence;

(e) incapacity to experience guilt or to profit from experience, particularly punishment;

(f) marked proneness to blame others, or to offer plausible rationalizations, for the behaviour that has brought the patient into conflict with society.

There may also be persistent irritability as an associated feature. Conduct disorder during childhood and adolescence, though not invariably present, may further support the diagnosis.

People with ASPD (Dissocial in ICD 10) show unreliability, recklessness, restlessness, disruptiveness, and aggressiveness. According to DSM IV-TR (2000) they have a pervasive pattern of disregard for, and violation of, the rights of others. Negative symptoms include lack of anxiety and remorse, and lack of emotional depth and stability. They are interpersonally detached, suspicious, and exploitative, and they lack commitment to and concern for others. Antagonism, deceitfulness, manipulativeness, dishonesty, and glibness are typical interpersonal features. Some come across as self-aggrandizing and self-justifying with a sense of entitlement and invulnerability. Cognitive deficits include inflexibility, and lack of concentration.

Prevalence

The lifetime prevalence of ASPD is about 2-3 % in the general population. The rate in the community and psychiatric population is relatively low (1-2%), but among correctional offenders, forensic psychiatric patients, and substance users it is high (< 50%).

Etiology

Theoretical models for the etiology of ASPD suggest a mental abnormality with social and biological causal factors, and have excluded child rearing experiences, familial dysfunctions, or adverse life experiences. Sociocultural and neurological factors are associated with symptoms of ASPD, but not clearly pathognomonic. Other theories consider ASPD as an extreme variant of personality traits found in all people, or as an adaptation. Early manifestations of ASPD are evident in children (age 6-10 years), and it is common that adults with ASPD in their childhood or adolescence were diagnosed with conduct disorder, oppositional defiant disorder, or attention deficit hyperactivity disorder.

Course

Symptoms of ASPD can persist into middle or late adulthood. ASPD has been associated with increased rate of morbidity and mortality.

Comorbidity

Antisocial personality disorder is often comorbid with substance-use disorders, but also with other personality disorders, such as the Cluster B borderline, narcissistic, and histrionic in DSM-IV or emotionally unstable and histrionic in ICD-10.

Treatment

There is no good evidence that ASPD can be successfully treated. Most treatment studies have aimed at reducing criminal behaviour in mixed groups of patients or offenders, including some with ASPD, rather than attempting to alleviate symptoms of ASPD. Nevertheless, structured psychosocial treatments that focus on the acquisition of important life skills, such as communication, assertiveness, and anger management skills are useful (Hemphill & Hart, 2002). Pharmacological treatments that target treatment-interfering symptoms, such as extreme hostility or impulsivity, may play a useful adjunctive role in certain cases.

A 23 years old woman reacted with depressive symptoms and suicidal thoughts to the death of her grandfather. She was treated with antidepressant medication without addressing the loss. Three years later after a suicidal attempt, she was admitted to hospital where she first presented with depressed mood and suicidal thoughts, but quickly engaged in vivid conversations with the others patients. She was discharged with the diagnosis of personality disorder, but soon re-admitted because of suicidal thoughts, and referred to an outpatient program specialized on treatment of personality disorder. Since childhood she had unstable mood, aggressive temperament and self-destructive behaviour (head banging). At the age of 10 she was sexually abused by an older man. Suicidal thoughts and urges to kill herself was first experienced at age 11. Since age 13 she has had multiple sexual partners but also one 7 year long relationship which was quite unstable with frequent conflicts and impulsive acts. She dropped out of school and has been living on sickness benefits, interrupted by short periods of unskilled employment. In a two year psychoanalytic treatment program with one individual session and one group session a week in addition to psycho education, she worked together with other patients on identifying and understanding the characteristic features of BPD, and the dynamics of borderline pathology with a special focus on self-destructive behaviour. Her self-destructive behaviour tapered off after 3 months as she began to process her feelings of aggression and sadness. The pharmacological treatment terminated after 6 months and she quickly became less sedated and anxious. She resumed school towards the end of the first year of treatment, with the intention of taking a degree in teaching. The relationship with her boyfriend stabilized. Contacts with class became more satisfying, and conflicts with her teachers stopped. Her ability to begin to contain feelings increased dramatically.

Clinical Description

Diagnostic Criteria ICD-10

F60.3 Emotionally unstable personality disorder

A personality disorder in which there is a marked tendency to act impulsively without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of intense anger may often lead to violence or "behavioural explosions"; these are easily precipitated when impulsive acts are criticized or thwarted by others. Two variants of this personality disorder are specified, and both share this general theme of impulsiveness and lack of self-control.

F60.30 Impulsive type

The predominant characteristics are emotional instability and lack of impulse control. Outbursts of violence or threatening behaviour are common, particularly in response to criticism by others.

Several of the characteristics of emotional instability are present; in addition, the patient's own self-image, aims, and internal preferences (including sexual) are often unclear or disturbed. There are usually chronic feelings of emptiness. A liability to become involved in intense and unstable relations hip s may cause repeated emotional crises and may be associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (although these may occur without obvious precipitants)

lncludes: borderline personality (disorder)

Individuals with BPD (Emotionally unstable in ICD 10) have according to DSM IV-TR (2000) a pervasive pattern of instability in interpersonal relationships, self-image and affects, and marked impulsivity. They show frantic efforts to avoid real or imagined abandonment, a pattern of unstable and intense interpersonal relationships and identity disturbance. They also present with impulsivity, recurrent suicidal gestures, affective instability, chronic feelings of emptiness, inappropriate intense anger. In severe cases transient stress-related paranoid ideation or severe dissociative symptoms are noticeable.

Prevalence

BPD is relatively rare in the general population (0.2%- 1.8%) while prevalence rate among psychiatric inpatient and outpatient is higher (15% – 25%).

Etiology

Early separations and losses, disturbed parental involvement with conflictual relationships, childhood history of physical and/or sexual abuse, and high prevalence of affective disorder in first-degree relatives of borderline probands are specific developmental and psychosocial factors for BPD (Zanarini & Frankenburg, 1997). Low level of serotonin, stress sensitivity and a tendency for impulsive aggression can, when combined with psychosocial factors, contribute to adult BPD.

Course

Although borderline patients improve over time they still can remain functionally impaired. Especially those who experienced sexual abuse or incest in childhood have a poor prognosis. Emotional instability, impulsivity and aggressive relationships worsen prognosis as do co-morbid substance abuse, and schizotypal, antisocial or paranoid features.

Comorbidity

Around 60% of patients with BPD have major depressive disorder, 30% panic disorder with agoraphobia, 12% substance use disorder, 10% bipolar-I, and 4% bipolar-II disorder. Comorbid BPD tends to interfere with treatment of Axis I.

A 42-year-old male professional in public office, was forced to resign after being arrested when visiting a brothel. In the aftermath he suffered from depression and considerable alcohol consumption, and was admitted for a three months treatment. He stopped drinking, but his depression remained nonresponsive to anti-depressant medication. Still without meaningful activities he felt empty and restless, and he was referred to psychotherapy. Developmental history indicates that at age 5 his father left the family, and they did not meet until he was in law school. He was always ahead of his age and went through school without difficulty. In law school he got high marks without hard work. He had many acquaintances but no friends, and he felt like an outsider. He got married and had two children. Reaching mid-thirties he felt bored. He had everything: house, career, and family. He was respected and accomplished, but felt he didn’t belong. He started drinking heavily and visiting brothels. The psychotherapist found him self-assured, easily irritated, and quick to make devaluating remarks, and felt a mixture of irritation, compassion and powerlessness. Interactions during weekly appointments were extremely difficult. Unwilling to explore his situation or his feelings, he blamed the therapist for the impasse and told him that he will not change and that the therapist could not help. The therapist dreaded the appointments, while the patient despite finding the sessions unhelpful, always showed up. When the therapist announced a three weeks break his patient suggested the treatment to end and did not return. Nine months later he informed the therapist that he moved to another city, had a leading position working with international trade, and was greeted as a king. He said nothing about his wife and children. Nor did he indicate how he felt about the treatment.

Clinical Description

People with NPD (not included in the ICD 10) have a grandiose sense of self-importance and accompanying grandiose fantasies. According to DSM-IV TR (2000) they present a pervasive pattern of grandiosity, need for admiration and lack of empathy. In addition they have a sense of entitlement and tendencies to be exploitive, and take advantage of other people. They can come across as arrogant and haughty or boastful and self-centered. However, they also have vulnerable and fluctuating self-esteem, feelings of shame, intense reactions to criticism or defeat, and vocational irregularities. Some may appear more sensitive, inhibited, vulnerable, shame-ridden and socially withdrawn, and others can present with psychopathic or antisocial characteristics.

Prevalence

Variable prevalence rate of NPD has been found both in the general community (1% - 6%) (Stinson, Dawson Goldstein et al 2008) and in the clinical population (1.3% - 17%).

Etiology

Studies have suggested a genetic influence on the development of NPD, including hypersensitivity, strong aggressive drive, low anxiety or frustration tolerance, and defects in affect regulation (Torgersen et al 2000; Schore, 1994). Inconsistent attunement and insufficient attachment in the early parent-child interaction can lead to failure in the development of self-esteem and affect regulation.

Course and prognosis

Although narcissistic traits can be frequent in adolescence, NPD develop in adulthood and can persist into old age. Severe disability has been indicated especially among those with comorbid Axis I disorder. NPD patients with ability for object relations actually improve over time and may have better prognosis (Ronningstam, Gunderson, Lyons 1995).

Comorbidity

NPD is considered to have one of the highest rates of diagnostic overlap among the Axis II disorders, especially with ASPD (25%). Major depression and dysthymia are the most common concomitant Axis I disorders (42 - 50%), followed by substance use disorder (24 – 50%) and bipolar disorder (5 – 11 %). Co-occurring narcissistic features can worsen course and prognosis for Axis I disorders.

Treatment

Psychoanalysis and psychoanalytically oriented psychotherapy are the most common treatment for NPD (Kernberg, 1975; Kohut, 1968; Fiscalini, 1994). Additional modalities include the Schema Focused Therapy (Young & Flanagan, 1998), and couples or family therapy (Solomon, 1998; Kirshner, 2001). Potentially beneficial psychopharmacological treatment focused on mood, anger or anxiety, is often challenged by the patients’ reluctance to adhere to such modality.

A 25-year-old female university student sought psychoanalytic treatment as she suffered from depression, difficulties in interpersonal relationships, and vocational dissatisfaction. Her first panic attack occurred during the last year in high school when her boyfriend was treated for panic attacks. She believed she was "influenced" by him. In psychotherapy she overcame family difficulties, especially in relation to her mother, but continued to feel insecure and pessimistic, blaming it all on her boyfriend. Their conflictual relationship ended when she had an episode of depression. She felt she wanted to die and sought consultation for psychoanalytic treatment saying that she was wasting her life, and lacked motivation for studies or career. She dreamt about her former boyfriend, and after breaking up with two other men she felt extremely lonely. She is the third of seven children. The father was hard-working, affectionate and caring, but also irritable and depressive. The mother was impulsive and sarcastic. Mother and daughter had a close but conflictive relationship as the mother could be intrusive, opinionated and idealizing. At age three the parents moved abroad for one year and left her to live with relatives. Upon their return she was presented to a baby brother. Significant sensitivity during her school years led her to break up friendships and feel extremely lonely. She did well at university, formed friendships but noticed that she often felt rejected without knowing why. In psychoanalysis four times per week she presented several contradictions, i.e., pursuing treatment and lapsing, or describing her mother as unsupportive, cold and envious but nevertheless readily resorting to her when facing difficulties. As the psychoanalysis progressed she presented infantile histrionic features; a precarious identity, strong affective dependence, dissociation, infantilization and self destructive work related behaviour. She brought multiple dreams to the sessions and gave vivid images of conflicts that worried her. Despite efforts to interpret, the analyst noticed no progress. Paradoxically, her presentation of dreams and associations indicated in-depth psychological work, but her persistent tardiness and absenteeism reflected the opposite. After eight months of psychoanalysis, the analyst suggested 3 sessions per week of face to face psychotherapy and referred her to a colleague.

(d) continual seeking for excitement and activities in which the patient is the centre of attention;

(e) inappropriate seductiveness in appearance or behaviour;

(f) over-concern with physical attractiveness

Associated features may include egocentricity, self-indulgence, continuous longing for appreciation, feelings that are easily hurt, and persistent manipulative behaviour to achieve own needs.

lncludes: hysterical and psychoinfantile personality (disorder)

In DSM-IV-TR (2000) HPD is described as a pervasive pattern of excessive emotionality and attention-seeking behaviour. People with HPD show seductive inappropriate behaviour, shallow emotional expressions, impressionistic speech, suggestibility, and a belief that relationships are more intimate than they really are. They have strong need for attention, pursued by a sensational physical appearance, or by being emotionally dramatic and expressive, or inappropriately sexually provocative or seductive. Individuals with HPD range from high level classical hysterical character neuroses to more primitive character functioning presenting with dissociative language, vivid fantasy life and infantile dependence.

Prevalence

DSM-IV-TR (2000) suggests that about 2% - 3% of the general population and 5% – 10% of the clinical population meet criteria for HPD.

Etiology

Repression and somatisation of strong emotions are considered the main etiological factors in hysteria.

Course and prognosis

The course and prognosis of HPD depends upon comorbidity and level of severity of the disorder. Intense and chronic anger and stormy close relationships are indicators of poorer prognosis. Ability to reflect and tolerate regularity can prevent treatment failure (Stone, 2005).

Comorbidity

Major depressive disorder, Somatization disorder and Conversion disorder are the most common comorbid Axis I disorder with HPD. Association between the other Cluster B personality disorders have also been found. Individuals with HPD can also present with increased attention driven risk for suicidal gestures and threats.

Treatment

Histrionic personality traits are usually requiring long-tem treatment and psychodynamic psychotherapy is the most common modality. Higher functioning neurotically organized individuals can be treated with psychoanalysis, while people with more primitive functioning may benefit from supportive or cognitive therapy which focuses on the patient's automatic thoughts and beliefs and on modifying emotional and interpersonal reactivity (Gabbard & Allison, 2007).

Cluster C includes the Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders. Individuals with these disorders often appear anxious or fearful. Avoidant Personality Disorders exhibit a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Dependent Personality Disorders show a pattern of submissive and clinging behavior that evidence an excessive need to be taken care of. Lastly, Obsessive-Compulsive Personality Disorders manifest a preoccupation with orderliness, perfectionism, and control.

The patient was a 35 year old, unmarried data technician referred to a specialized treatment program for personality disorders from an out-patient drug addiction service. His personality pathology was considered more devastating than his substance abuse. Presenting complaints included low self esteem, loneliness, sense of emptiness, suicidal ideation, social isolation, substance abuse, general dissatisfaction with life. Present complaints had been chronic in nature, dating back to childhood. He recalled having daily suicidal thoughts for several years in his early youth. On axis I he fulfilled the criteria for dysthymic disorder and drug abuse in partial remission, but not panic disorder or social phobia. His avoidant behavior was more prominent than his level of experienced anxiety. On axis II he fulfilled all seven criteria for avoidant personality disorder and an additional seven criteria spread across other personality disorders. The most prominent feature was a pervasive fear of being ridiculed when interacting with others. In a group-based treatment program lasting for 20 weeks, he was a regular, but somewhat detached participant. The therapists encountered a series of problems related to passivity: He postponed most of his obligations, resisted sorting out practical affairs, did not pay his bills and avoided contacting people who could be helpful.

Clinical description

Diagnostic Criteria ICD-10

F60.6 Anxious [avoidant] personality disorder

Personality disorder characterized by:

(a) persistent and pervasive feelings of tension and apprehension;

(b) belief that one is socially inept, personally unappealing, or inferior to others;

(c) excessive preoccupation with being criticized or rejected in social situations;

(d) unwillingness to become involved with people unless certain of being liked;

(e) restrictions in lifestyle because of need to have physical security;

(f) avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.

Associated features may include hypersensitivity to rejection and criticism

Avoidant personality disorder is a pervasive pattern of social inhibition, feelings of inadequacy or inferiority, and hypersensitivity to negative evaluation, according the definition of American Psychiatric Association DSM-IV-TR (American Psychiatric Association, 2000). The term of avoidant personality disorder has been used in DSM, while anxious personality disorder is used in ICD-10 (World Health Organization, 1993). Although the term avoidant personality disorder was first used by Millon, (1969) these patients have been described as sensitive character (Kretschmer, 1921), introvert (Jung, 1936), interpersonally avoidant (Horney, 1945)), insecure psychopath (Schneider, 1950), phobic personalities (Fenichel, 1945), or active-detached personalities (Millon, 1973). People with this disorder are timid, extremely self-conscious and fearful of criticism, humiliation, and rejection.

Comorbidity

Clinical literature has reported that Cluster C personality disorders including avoidant personality disorder often co-occur with mood and anxiety disorders. Avoidant and dependent personality disorders were strongly related to mood disorders, especially major depression, dysthymia, and mania. Avoidant personality disorders were reported to be strongly related to anxiety disorders, especially panic disorder with agoraphobia and social phobia. In addition to mood and anxiety disorders, eating disorders tend to be comorbid with avoidant personality disorder (Oldham et al. 1995). Avoidant personality disorder often co-occurs with other Cluster C personality disorders. This disorder is especially strongly correlated with dependent personality disorder.

Prevalence

Although there was concern that the prevalence of avoidant personality disorder might be low when it was first included in the DSMIII classification system, it became clear that this is one of most common personality disorders. However, this disorder appears to be more prevalent according to the recent national studies with a large sample size e.g., 2-2.5%. It is quite prevalent within clinical settings and reported to present 5% -35% in psychiatric populations (Mattia et al. 2001). The odds of avoidant personality disorder are greater for the lower income group, people with less than a high school education, the widowed/divorced /separated and never married, and residents in the most urbanized areas (Grant et al., 2004).

Etiology

Although the etiology of avoidant personality disorder is not known, a few models are proposed. The biological learning theory hypothesizes that the interaction of a biologically determined sensitivity to interpersonal relationships and social experiences affects the development of the disorder. It is also postulated to be an extreme variant of the personality traits of introversion and neuroticism which have heritability. According to the interpersonal etiology model, the disorder is explained based on a conflict between seeking closeness and fearing it. Cognitive theory hypothesizes negative schema which originate in early childhood, and which lead to social avoidance behavior. When the disorder begins in childhood, the symptoms could worsen in adolescence due to the complex and demanding social relationships of this time.

Treatment

It is essential to establish a good therapeutic relationship which is, however, very difficult because of the patients’ low self-esteem and hypersensitivity to rejection. Cognitive individual or group format is effective for these types of patients. Social skills training, systematic desensitization, and graded hierarchy of in vivo exposure to feared social situations could be useful (Beck & Freeman, 1990). Both short-term dynamic psychotherapy and cognitive therapy have a place in the treatment of patients with cluster C personality disorders (Svartberg et al. 2004). Exploratory and supportive group therapy may be helpful for these patients by providing a holding environment in which they can share their insecure feelings.

The patient was a 27 year old white female administrative assistant whose work required much use of the computer and data entry. She gradually began to develop pain in her wrists. Physicians diagnosed a potential carpal tunnel syndrome. The damage to her wrists was not reparable by surgery and Sally was left in significant daily pain. The patient demonstrates the key aspect of Dependent personality, the need to please others even at the expense to herself. The degree to which her self-destructive passivity and compliance at work stemmed from her early experiences within the family are unclear, but her parents’ overprotectiveness likely played some role in the etiology of her personality pathology. Research confirms that overprotective and authoritarian parenting, alone or in combination, often lead to excessive interpersonal dependency in offspring.

Clinical description

Diagnostic Criteria ICD-10

F60.7 Dependent personality disorder

Personality disorder characterized by:

(a) encouraging or allowing others to make most of one's important life decisions;

(b) subordination of one's own needs to those of others on whom one is dependent, and undue compliance with their wishes;

(c) unwillingness to make even reasonable demands on the people one depends on;

(d) feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself;

(e) preoccupation with fears of being abandoned by a person with whom one has a close relationship, and of being left to care for oneself;

(f) limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others.

Associated features may include perceiving oneself as helpless, incompetent, and lacking stamina

Although early diagnosticians discussed at length the clinical implications of exaggerated dependency needs, it was not until publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) that dependent personality disorder (DPD) became a full-fledged diagnostic category. DPD is defined as "a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation" (APA, 1994, p. 668). The person must show several of the following symptoms to receive a DPD diagnosis: difficulty making everyday decisions without excessive advice and reassurance; needing others to assume responsibility for most major areas of life; difficulty initiating projects or doing things on one’s own; going to excessive lengths to obtain nurturance and support; feeling uncomfortable and helpless when alone, being unrealistically preoccupied with fears of being left to care for oneself.

Comorbidity

The DSM-IV-TR indicates that three Axis I diagnoses - mood disorders, anxiety disorders, and adjustment disorder - show substantial comorbidity with DPD. Evidence supports continued inclusion of these three categories in future versions of the DSM, but also suggests that eating disorders and somatisation disorder co-occur with DPD at higher-than-expected rates (Piper et al. 2001).

Prevalence

Problematic dependency is widespread in the community as well as in clinical populations, and is associated with an array of psychological disorders. Studies typically report Dependent Personality Disorder prevalence rates of between 15 % and 25% in hospital and rehabilitation settings (Oldham et al. 1995). Bornstein’s (1993, 1997) meta-analyses of epidemiological findings indicated that gender moderates DPD prevalence rates. When data from extant studies were combined, the overall base rate of DPD was 11% in women and 8% in men. Although this difference seems modest, it is highly significant.

Etiology

Several theoretical frameworks have been particularly influential in conceptualizing the etiology of the Dependent Personality. Research does not support the early psychodynamic hypothesis that variations in infantile feeding and weaning behaviors play a role in the development of dependent personality traits (Bornstein, 1996). Many psychodynamic researchers (e.g., Luborsky & Crits-Christoph, 1990) now conceptualize problematic dependency as resulting from unconscious conflicts. Cognitive models of DPD focus on the ways in which a person’s manner of thinking helps foster dependent behavior. As Freeman and Leaf (1989) noted, dependency-related automatic thoughts (i.e., reflexive self-statements that reflect the person’s perceived lack of competence) are central in this process. Automatic thoughts are accompanied by negative self statements, which combine to create a persistent attributional bias that reinforces the person’s view of himself as vulnerable and weak. A vicious cycle ensues.

Treatment

No studies have documented the long-term course of DPD in inpatients, outpatients, or community adults. In the short term, research confirms that dependent patients exhibit behaviors that both facilitate and undermine treatment. For example, dependent psychotherapy patients are cooperative and conscientious, but also make more requests for after-hours contact. Dependent patients delay less long than nondependent patients when psychological symptoms appear, but they also have difficulty terminating treatment after symptoms remit (Bornstein, 1993). Over the years clinicians have provided recommendations for intervention strategies based on cognitive (Young, 1994), psychodynamic (Luborsky & Crits-Christoph, 1990), behavioral (Turkat, 1990), and experiential (Schneider & May, 1995) treatment models. However, only two studies assessed changes in DPD symptoms during the course of psychotherapy, and these investigations produced conflicting results.

The patient was a 42-year-old single male, who lives with his parents. He has been unemployed for some time. He presented to the anxiety disorders clinic at a major teaching hospital, because of concerns regarding his long-term unemployment. He tended to procrastinate when making decisions or carrying out plans. On weekends, when the family planned to visit the grandparents he would start packing on Friday afternoon, but on many occasions did not finish the packing until Sunday, by which time it was too late to go. He spent long periods of time in the bathroom, would take half an hour to wash his hands-first washing the tap, then his hands, then the tap again. This routine also made it difficult for him to go out and look for job. In fact, it totally prevented him from doing so. After leaving school, he has had 30 or 40 jobs, mostly factory work. The longest he has lasted in a job has been one week, often only one day. He was very punctual in treatment and never missed a session; he talked freely, and in great detail. The initial part of therapy mainly dealt with family relationships. When the time came to leave the sessions he would often continue talking and delaying even when the therapist was standing at the door.

Diagnostic criteria of ICD-10 (WHO, 1992) and DSM-IV-TR (APA, 2000) for the OCPD (or anankastic personality disorder, following the ICD-10) are quite similar. Both nosological systems describe a syndrome characterized by symptoms such as excessive perfectionism, stubbornness, rigidity, and lack of decision. For the DSM-IV-TR, the OCPD is a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts.

Comorbidity

Most research shows that most individuals with Axis I Obsessive-Compulsive Disorder do not fulfill the criteria of OCPD. Furthermore, it has been found that patients with OCD and with a personality disorder show similar or more frequent relationships with the avoidant or dependent personality disorder than with OCPD. Comorbidity with other personality disorders has varied markedly depending on the specific study.

Prevalence

(Maier et al. (1992) found that the Obsessive-Compulsive Personality Disorder was the second most frequent personality disorder (among the 11 included in the DSM-III-R) in his study sample (individuals without psychiatric disorders), showing a range from 1.6% to 6.4%, while the prevalence found by Widiger & Sanderson (1997) ranged from 1% to 3%.

Etiology

The etiology of Obsessive-Compulsive Personality Disorder is unknown. There are not data regarding the influence of biological factors in the onset and development of this disorder, but it is believed that environmental factors play an important role in its etiology. Millon (1996) proposes some of these tentative variables: parental over-control is a method of restrictive child-rearing in which punitive processes are used to set distinct limits on children’s behavior. As long as they operate within the parental approved boundaries, children are safe from parental punishment. The acquisition of behavior patterns of OCPD are learned vicariously and by imitation.

Treatment

Neither pharmacological, nor psychoanalytical, interpersonal, or cognitive-behavioral perspectives have empirical proven techniques for the modification of OCPD. One of the most frequent symptoms present in individuals with OCPD, causing inefficiency is their inability to give priority to important tasks instead of focusing on trivial or less important tasks, and also their inefficient distribution of time. A coping strategy would be good management of time strategies. Furthermore, these strategies would allow the individual to save time and devote it to other leisure and social activities.

Westen, D. (1997). Divergences between clinical and research methods for assessing personality disorders: Implications for research and the evolution of axis II. American Journal of Psychiatry, 154, 895-903.

What are the most striking gender differences among personality disorders – i.e., which disorders are, according to the text, most common among men, and among woman? How does that compare to your cultural experiences? Discuss reasons for observed differences

How does the prevalence of each personality disorder vary in your country/culture compare to those prevalence rates mentioned in the Module II text?

Discuss and compare the differences between treating personality disorders and Axis I disorders. How do co-occurring Axis I disorders influence treatment of a personality disorder, and vice versa, how can the presence of a personality disorder affect the course and treatment of an Axis I disorder such as Bipolar disorder or Major Depression or Eating Disorder. Give examples.

Compare the major contemporary controversies of each personality disorder and discuss future changes in diagnostic classifications and important areas for research.